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Acute isoniazid neurotoxicity in an urban hospital
B R Shah1, K Santucci, R Sinert
1Department of Pediatrics, Children's Medical Center of Brooklyn, State University of New York 11203-2098, USA.
Insights
Acute isoniazid (INH) neurotoxicity increased with tuberculosis resurgence. Children presenting with seizures, especially with INH exposure, should be evaluated for toxicity. Prompt pyridoxine administration is crucial for managing INH-induced seizures.
Area of Science:
- Pediatric Neurology
- Toxicology
- Infectious Disease Epidemiology
Background:
- Tuberculosis (TB) resurgence in urban centers has led to increased use of isoniazid (INH) for prophylaxis and treatment.
- Acute isoniazid neurotoxicity is a rare but serious adverse effect, particularly in pediatric populations.
- Understanding the presentation and management of INH neurotoxicity is crucial for timely diagnosis and intervention.
Observation:
- A case series identified seven pediatric patients treated for acute INH neurotoxicity between 1991 and 1993, contrasting with zero cases from 1985-1990.
- This increase paralleled a rise in pediatric TB cases at the institution, from 96 to 213 annually.
- Patients presented with seizures, often afebrile, following accidental ingestion or intentional overdose of INH.
Findings:
- The mean ingested dose was 54 mg/kg (range 14.3-99.3 mg/kg).
- Two patients with refractory seizures required parenteral pyridoxine for control after failing anticonvulsant therapy.
- Diagnostic delay occurred due to INH neurotoxicity not being initially suspected.
Implications:
- Increased incidence of acute INH neurotoxicity is linked to the resurgence of TB.
- Pediatricians and emergency departments should maintain a high index of suspicion for INH toxicity in children with seizures, especially with known INH exposure.
- Parenteral pyridoxine should be readily available in emergency departments to manage INH-induced seizures effectively.
Objectives:
To describe the presentation and treatment of acute isoniazid (INH) neurotoxicity appearing at an inner-city municipal hospital.
Design:
Case series.
Participants:
Seven patients (eight patient visits) with an age range of 5 days to 14.9 years.
Results:
At our institution, no children appeared with acute INH neurotoxicity in the period 1985 through 1990, whereas seven patients were treated from 1991 through 1993. This paralleled the rise in the number of children with tuberculous infection and disease seen at our institution, from an average 96 per year to 213 per year during these two time periods. All seven patients were receiving INH daily for tuberculosis (TB) prophylaxis. Accidental ingestion (five episodes) and suicidal attempts (three episodes) accounted for these visits. The total amount ingested range from 14.3 to 99.3 mg/kg (mean, 54 mg/kg). All but one patient presented with afebrile seizures. One patient presented twice with seizures. Acute INH neurotoxicity was not suspected on the first admission; however, when readmitted 4 weeks later with another seizure, the diagnosis of acute INH neurotoxicity was made.
Intervention:
Intravenous pyridoxine was used in five episodes. Because it was not a stocked item in our pediatric emergency cart (as well as at another hospital, necessitating a transfer of a patient with refractory seizures to our hospital), the average delay was 5.8 hours (range, 1.3 to 13 hours) before it was given. Two patients with refractory seizures failed to respond to anticonvulsants, and their seizures were controlled only after parenteral pyridoxine.
Conclusions:
We have seen an increased incidence of acute INH neurotoxicity because of the resurgence of TB in New York City. Others as well may see a similar rise based on local trends in TB infection and disease. Acute INH toxicity should be suspected in children presenting with seizures with or without fever. In patients with a known access to INH, seizures should be considered to be caused by INH toxicity unless proved otherwise. Parenteral pyridoxine, the specific antidote for INH-induced refractory seizures, should be readily available in every emergency department in the areas similarly experiencing increasing trends of TB.